Electronic Journal of Human Sexuality, Volume 2,
October 10, 1999

(The present paper is adapted from two articles which first appeared
in San Francisco Medicine, Nov./Dec. 1998, pp. 23-26. A different
version is included in Moser, C. (1999) Health Care Without Shame,
San Francisco: Greenery Press).

Part I - Some Background for the Practitioner

Sexual minority is a term used to describe those who identify as other
than monogamous heterosexuals. It is specifically thought to include the
transgendered, those with multiple sexual partners, sex workers, and S/M
practitioners. Physicians and other health care practitioners have just
begun to address the special health and lifestyle issues of the gay, lesbian
and bisexual patients. However, the medical concerns of other sexual minorities
have not been addressed in a meaningful way. The present article is hopefully
a beginning for physicians and other health care professionals to address
the health concerns and needs of all patients involved in alternative sexual
behaviors or lifestyles. [Throughout the present article, the term "physician"
will be used to include all health care providers].

The first question healthcare providers need to answer, is whether they
really wish to treat such patients. Some physicians are unable to overcome
their own personal issues about alternative sexual behaviors and should
refer these patients. Even sexual minority physicians may not able to overcome
their own issues to treat other sexual minority patients nonjudgmentally.
Just because these patients are referred, does not relieve the physician
of the responsibility of learning the basics of their care. Most physicians
do not speak Mandarin, so it is reasonable to refer new Mandarin-only speaking
patients to a Mandarin-speaking physician. Nevertheless, sometimes referral
is not an option. When necessary, one should use translators (professional
translators, Mandarin speakers who work in the hospital and family members).
The physician should also learn something of Chinese culture. Hospitals
have devised "Asian diets" (comfort food is important when you are sick)
and have made other accommodations. Physicians confronted with sexual lifestyles
with which they are not comfortable need to take similar actions: Seek
out experts and attempt to make accommodations for patient comfort. If
you decide that treating sexual minority patients will be a significant
aspect of your practice, the present paper contains some recommendations
on how to treat them effectively and respectfully.

Who they are vs. what they do

In treating sexual minority patients, one must distinguish between identity
and behavior - a task not as simple
as it seems. Individuals may choose a label to define their sexuality,
but their actual behavior may be very different. Medical risk is associated
with behavior, heredity or environment, not identity. It does not matter
whether a male patient identifies as gay, but it does matter if he has
sex with men. Additionally, anal sex with a man opens him up to different
medical risks than anal sex with a dildo-wielding woman.

Nevertheless, identity is also an issue. A woman who self-defines as
a lesbian is often subjected to a variety of stresses that a heterosexual-identified
woman is not, without regard to behavior. There are social stressors regarding
partner choice ("Will my partner be
allowed to visit in the intensive care unit? What will happen when my co-workers
meet my lover?"). There are also genuine physical dangers -
rape, assault and even homicide - associated
with being identified as gay, lesbian, a sex worker, an S/M practitioner,
or transgendered, as the crime sheet in any city can attest.

Sexual identity and behavior are fluid. There are people who at different
times have defined themselves as gay, straight and bisexual in every possible
sequence. It can be hard to imagine, but there are people who at are not
quite sure which gender they are, who are frustrated that no one will acknowledge
their chosen gender, or who finds any gender at all intolerable. Is a woman
who is happily married, but secretly desires sexual contact with other
women, a lesbian or bisexual or even heterosexual? Does that orientation
change if she begins an affair with another woman, if she leaves her husband,
or even if she becomes celibate? There are no simple answers. Just remember
that identifying with one sexual orientation, does not describe an individual's
actual behavior. Acceptance of this fluidity is the first step in providing
nonjudgmental health care and not alienating your patient.

Your sense of the patient's probable
identity may not reflect the patient's
own self-identification; youare
not a mind reader and appearances are deceptive. Be aware that individuals
tend to categorize someone into the less societally accepted role, if given
the option. A "heterosexual" man who has sex with men is assumed to be
a really gay, but a "homosexual" man who has sex with a woman is not assumed
to be a really straight. The same phenomenon is even more apparent when
applied to other sexual minorities.

No assumptions.

Associating certain medical problems with a specific sexual minority
acts to stigmatize that minority. Clearly unprotected anal coitus is a
risk factor for HIV transmission, but more heterosexuals take part in anal
coitus than homosexuals. The point is; talk with all your patients
about anal safer sex practices. The assumption that you can choose whom
to advise will unfortunately be proved wrong far too often.

Anal sexuality is often a forgotten area in medical school. Possibly
the best piece of advice to give patients interested in exploring anal
sex, is to make sure anything inserted into to the anus has a flange to
prevent it from being lost in the rectum. A second safety technique that
also should be advised is attaching a string to the object. This allows
for retrieval if the flange fails to prevent the object from being lost
in the rectum. Discussions of how to prevent colonic perforations (smooth
soft toys, exceedingly short fingernails, and quick referral for bleeding)
should also be emphasized, in addition to safer sex advice. Information
about sexually transmitted diseases (STD's) that can be transmitted by
anal sex or oral/anal contact should also be reviewed.

Is your office sexual minority friendly?

Your prospective patient's first
contact with your practice is your office staff and your forms. Patient
information sheets routinely ask questions that may seem simple and routine,
but are really quite difficult. Prospective transgendered patients must
choose between indicating they are male and female; S/M practitioners must
choose between listing their spouse or their S/M mistress as their emergency
contact. How does the newly married gay patient indicate that on your forms?
A new patient will judge your paperwork, before ever finding out how accepting
you are.

Your office staff can also be the cause of a misunderstanding. The following
examples illustrate genuine obstacles to obtaining health care for sexual
minorities: The odd look from your receptionist, the nurse who does not
understand the need to have a chaperone when examining a female-to-male
transsexual, the medical assistant who shudders when seeing nipple rings,
and the bookkeeper who refuses to explain a charge on the bill to the patient's
significant other. All these can represent genuine obstacles to obtaining
health care for the sexual minority patient.

The somewhat unfriendly form or staff can all lead to a hostile or fearful
patient. It is probably a good idea to review your patient materials to
make sure they are not inadvertently offensive. A frank discussion with
your office staff, letting them know that you welcome sexual minority patients
into your practice and will not tolerate any disrespect, can also be useful.
Be especially aware of the staff member who is tolerant of most sexual
minorities, but frightened or upset by a particular sexual lifestyle or
behavior; perhaps some education on your part can help allay this person's
qualms.

Your own first impression

A physician who is not knowledgeable or respectful about sexual minority
practices often reveals that ignorance in the initial history and physical.
Consider some more informed ways of asking questions:

Rather than ask Amarital status?"

Ask, "Are you single, married, divorced, separated, or partnered?"
The next question is "With whom do you live?"

Rather than "What form of birth
control do you use?

Ask, "Do you use birth control?"
If the patient says yes, then ask, "What
methods do you use?" If the patient
says no, then ask, "Do you need birth
control?" (If you ask the "need" question
first, you will overlook the patient who is relying on the rhythm method.)

Rather than "Do you have any sexual
problems?

Ask, "Do you have any sexual
concerns?" Then follow up with more
detailed questions: General questions alone will not uncover sexual dysfunctions.
You have to ask about each specific dysfunction: For example, do you have
difficulty having an orgasm, getting an erection, maintaining an erection,
experience pain during sex, having an orgasm too soon, lubricate enough
or long enough, and do you desire sex? Also, the phrase Asexual
concerns" allows the patient to bring
up concerns other than dysfunctions.

Rather than "With how many partners
do you have sex?"

Ask, "Are you currently having sex with
anyone?" If the patient says "no," you can ask "Is that a problem for you?"
If the patient says "yes," you can ask, "Do you have more than one partner?"

Rather than "Who beat you up?"

Ask, "how did you get those marks/bruises/welts?"

Rather than "What is your sexual
orientation?"

Ask, "Do you have sex with men, women or both?"

Finish the sex oriented part of the interview with, "Do
you engage in any sexual activities about which you have health questions?"

Respecting your patients' identity
and relationships.

It seems only courteous to refer to patients as they request. Nevertheless,
it can be difficult to remember to refer to your budding, but balding,
male-to-female (MTF) transsexual patient as "she"
- to write "Frank"
on the prescription, but call her as "Francesca."
It can be hard to remember to do a Pap smear on Dick, your female-to-male
(FTM) transgendered patient.

It is respectful to include the patient's
significant other in major decisions, if that is the
patient's
desire and despite the relationship's
legal status. Sometimes it is difficult to ferret out the relationships
that are important to your patient. Your patient may have a wife and a
master, or two significant others. It is appropriate and desirable to ask
the patient who they would like present.

Dealing with the mistrustful patient.

Many sexual minority patients mistrust traditional medicine. Some of
this attitude is understandable. Many alternative sexual behaviors are
also psychiatric diagnoses, and in some cases are illegal; many patients
have had less than pleasant interactions with non-accepting physicians.
Reliance on alternative medicine, folk remedies and the avoidance of traditional
medicine are common. Sexual minority patients tend not to attend to health
care maintenance or even simple problems. So when they finally seek medical
care, there can be serious medical concerns.

For similar reasons, many sexual minority patients also mistrust mental
health professionals - so a suggestion that your patient see a psychiatrist
or psychotherapist may be greeted with skepticism or hostility, particularly
if the patient believes such therapy is an attempt to "cure" the patient's
sexual behavior. It goes without saying that consensual and satisfying
sexual behaviors among adults, which do not interfere with the patient's
functioning, do not need curing. Nevertheless, depression, personality
disorders, stress and other psychiatric problems are at least as likely
among sexual minorities as in the general population. Due to the stresses
of living a non-traditional lifestyle, some emotional difficulties may
be more common. Illicit drug fads within (and outside) the various sexual
minority communities also may lead to psychiatric and medical problems.
Sensitive physicians are able to assure their patients that they are recommending
mental health treatment because of the psychiatric problem and not because
of the sexual behavior.

Sexual minority patients are concerned, often with cause, that health
care providers will pathologize them because of any of their sexual identities
or behaviors. You will have better success with these patients if you can
assure them truthfully that you do not consider their sexuality to be,
in and of itself, a problem.

Part II: A Brief Glossary of Sexual Minority Terms.

The following glossary is meant to help health care practitioners understand
their patients' sexual language. It is not a complete list and not everyone
will agree with these definitions, but it is a start. An accepting attitude
and honest curiosity will take you a long way. Nevertheless, heed the following
warnings:

Do not use these terms yourself; it is very easy to make a faux pas.
Many of these terms have different meanings and pejorative implications
when used by someone outside the patient's sexual community; you will be
misunderstood!

Even though these terms have pejorative meanings when used by "outsiders,"
they are not considered insulting when the patient uses them to self-describe
or to describe friends or lovers.

Do not assume thatsexual activities
are limited by one's stated sexual identification.

The definitions of these terms are seriously debated within the sexual
minority communities. These definitions are approximate and they do change
over time.

The italicized information interspersed below is to give the reader additional
information, and a very brief overview of some of the special questions
and issues that may be raised during your interactions with sexual minority
patients.

Sexual minorities (everything but the traditionally heterosexual)
call themselves or their activities queer, perv, pervert, kink, fetish,
leather or leathersex. Those who are not sexual minorities
are called vanilla or straight; vanilla
is also used to describe non-kink sexual activities. To be
squickedis to be upset or disgusted by a given behavior.

Someone who is coming out (exploring the activity or beginning
to accept the identity) is called a novice or newbie.
An attractive partner is cute or hot; hot is
also used to describe a particularly exciting interaction. Someone who
loves sex(orgasm-seeking behavior) or a specific sexual
activity is called aslut. Sometimes there is a specific
type of sex that is desired, e.g., pain slut, fuck slut,andanal slut.

So many synonyms exist for male and female masturbation, genitals, and
breasts, that it is impossible to list all of them here. Most are in relatively
common use outside the sexual minority communities. It is worth noting
again, that many terms - for example, the word cunt - do not carry
the pejorative implications in these communities that they do in the outside
world.

If you are not used to this sort
of language, it can be difficult not to react negatively when you hear
words you have always been taught are insulting or obscene. Nevertheless,
the patient may not know or understand medical or polite jargon.

People who eroticize physical and/or psychological pain (sometimes called intensity
or
erotic intensity) are called players and
are intoS/M (a.k.a. BDSM, sadomasochism, dominance
and submission or D/S, leather, and bondage and discipline or B/D).
Some people attempt to live this as a lifestyle,24/7 (24
hours a day, 7 days a week) or TPE(total power exchange).
Slave
contracts codify the rights and obligations of each partner in
the relationship; although these contracts have no legal status, they often
carry significant moral weight. Otherplayersonly do S/M
during sexual interactions; they do EPE(erotic power exchange)
or keep it in the bedroom. Players usually describe
their activities as SSC (safe, sane and consensual). A play
party is a social gathering where S/M activities take place;
the party space (venue) usually has equipment
(large
devices to which a partner can be secured). The players usually
bring their own
toys (handcuffs, whips, canes, etc.).

Toys are typically designed to provide sensory stimulation with minimum
physical damage, but they can be misused. Most cities have one or more
stores or organizations that teach safe use of these toys. There are also
books and magazines available containing such information.

Mixed playor cross-orientation play implies
an S/M interaction between people who would not usually have sex
together (a gay man with a lesbian, for example). S/M partners engage
innegotiation, the process of agreeing what will constitute
the specifics of the S/Mscene (interaction). They decide
upon a safeword (a word or gesture that will stop the scene)
and mutually define the limits (activities not to be included
in thescene).

Playerswho take the active role are called dom,
domme, top, master, mistress, and
sadist. Players
who
take the passive role are called submissive, sub, subbie, bottom,
masochist, boyorgirl,andslave.
(In some S/M interactions, it may not be immediately obvious
which partner identifies as the active partner and which as the receptive
partner). Switches can take either role. Within the S/M
community, there is often intense debate concerning the distinctions among
these terms; statements like "I am a masochist, I will be
submissive
if my partner enjoys it, but I am no one's slave" are not
uncommon.

Whipping, flogging, caning, spankingare common S/M
activities. Flogging involves an instrument with several
strands of leather or other material to strike one's partner. A single-tail is
a braided implement that tapers to a narrow end. The most common place
to strike is the buttocks, but thighs, shoulders, and genitals are also
common. Marking(leaving bruises, welts, or generalized redness)
is common, but not mandatory. Some individuals especially enjoy
playinvolving a specific area of the body, e.g., tit torture, CBT
(cock and ball torture), andcunt torture.
Edge
play(activities that tend to squick people
and are more dangerous) include blood play (shallow piercings
or cuts that draw small amounts of blood), knife play (using
a knife to scratch or cut, or to threaten), electricity(using
devices such as TENS units to deliver shocks), and breath playorcontrol(strangulation and suffocation).

These activities are not inherently abusive, criminal or self-destructive.
They typically are loving, intimate and well thought out in terms of safety.
A standard criterion for S/M play is that it should not cause damage requiring
professional intervention to heal (e.g. broken bones, deep lacerations,
etc.). However, even careful players sometimes have accidents. It can be
useful to compare S/M play to contact sports (football) or high-risk activities
(mountain climbing). Injuries do happen in these activities, some are accidental
and some indicate that the participant needs more safety training.

Men interested in bears(big, barrel-chested and usually
bearded men) are called cubs. Men attracted to men with large
penises are called size queens. Daddyand boy
imply an S/M relationship; women can use the same terms.

Women who are interested in sexwith other women are lesbians
or dykes. High femme or lipstick lesbians
are women who appear stereotypically feminine (lipstick, make-up, high
heels, frilly clothes, etc.). Femme women may also have a
decidedly feminine appearance, but not to the extreme. Soft butch
women have a more androgynous appearance. Stone butch women
tend to be masculine in appearance and may dislike any vaginal penetration
themselves. It is common to see a femme woman partnered with
a butch, but other pairings are not unusual. These roles
may not be all encompassing, it has been said "Butch in the streets,
femme between the sheets."

It can be tempting to try to impose the structures of typical
heterosexual relationships on same-sex pairings, looking for the "man"
and the "woman." While some same-sex couples identify with this paradigm,
many do not, and will be extremely offended if you make assumptions regarding
their roles.

Bisexualsorbi's are
sexually attracted to both men and women. There are political forces that
impel people to either embrace or deny the term bisexual;
as one woman told me, "If gay men
can have sex with women, why can't lesbians have sex with men."

Many people engage in sexual behavior with both men and women without
identifying as bisexuals. Additionally, do not assume that bisexuals are
always non-monogamous; bisexuality is a matter of identity and attraction,
not necessarily of behavior. Safer sex and birth control counseling needs
to be inclusive.

Men who like "lesbians" are called dyke daddies, but sometimes
this term is used instead to mean butches and transgendered
women interested in daddy/boy play. Heterosexual women who
like gay men are called fag hags or fruit flies,
but these terms do not usually imply sexual activity. Some lesbians interact
erotically with gay men and/or in gay male environments.

Many sexual minority members like to blur the boundaries of gender
with pronoun confusion. You may hear someone refer to a butch as "he" or
an effeminate man as "she."

A permanent or semi-permanent marking is called abody mod (modification),
and is attained by tattooing (tats), cuttings (a design
superficially or deeply cut into the skin by a knife or scalpel), piercings
(placement of metal bars or rings through the flesh). Burns or
burninginvolve using intense heat - matches, cigars, sticks of incense - for
sensation only, without attempting to create a design; they are usually
thought to be temporary (healing in a matter of weeks), but can be permanent.
Branding is the use of heat to make a permanent mark or design.
Piercings have specific names for the different locations; some of the
most common include
Prince Albert or PA (though
the frenulum area of the glans out the urethra),
guiche (perineum)
and triangle(above the clitoris). Some people like the act
of piercing and do needle playor play piercings,
which are removed at the end of the scene.

Body modifications typically heal themselves within a matter of weeks
or months without medical intervention. Many patients, if they encounter
trouble with a body modification, will turn to the body modification artist
for counsel rather than seek medical advice. If the artist's advice doesn't
work, they will come to you - typically with a serious infection. If you
treat many members of sexual minorities, it might be worthwhile to learn
more about body modifications and their ramifications, and perhaps to form
affiliations with some of your local body modification studios.

A relatively common activity for both men and women is handballing
or fisting, placement of a hand in the partner's
anus or vagina. After the hand is inserted, it is curled into a loose fist,
hence the name. Oral-anal contact is called rimming. A butt
plug is a sex toy for insertion into the rectum. Astrap-on
is a dildo(artificial phallus), worn in a harness that allows
one to engage in coitus with one's partner despite anatomy or physiology.
An individual who enjoys anal coitus(butt fucking or
pumping
the poop shoot) is called a back door betty or an anal
slut. Felching is the act of sucking one's cum
(semen) out of a partner's rectum, and sometimes sharing it orally
with the original recipient.

Not all the most "shocking" sexual activities are the most dangerous,
and vice versa. If your patient trusts you enough to tell of engaging in
some of these behaviors, a nonjudgmental consultation on the possible health
ramifications (HIV, Hepatitis, other STDs, as well as physical injury to
the rectum or colon) of what s/he is doing. Some of these activities are
not particularly risky from a health standpoint, and many of the risks
that do exist can be easily mitigated with latex barriers and other prophylactic
strategies.

When your partner is aware that you have or could have more than one
partner, you have an open relationship. Many people in open
relationships have an SO (significant other) or
primary
partner, and the other relationships are called secondary or fuck buddies. Those who are open to more than one primary relationship
are called poly or polyamorous. Individuals
who are straightforward and honest about their activities are called ethical
sluts. Fluid-bonded describes a relationship agreement not
to use safer sex precautions among those partners, but are mandatory with
other partners. Swingers are male-female couples who seek
other couples, but will occasionally allow a single to join them. The gay
male version of swinging occurs at the bathsor a
bathhouse.
Venues designed for swinging or
group sex are
also called sex clubs or sex parties; they
usually have a group roomfor group sex. Group
sex involves orgasm-seeking behavior by three or more individuals
at the same time. Female-only sex parties also exist but
are less common.

Non-monogamous relationships can be as healthy as any other relationship
style. People in ethically non-monogamous relationships can and do maintain
long-term commitments and raise happy families. The kinds of behaviors
encountered among the nonconsensually non-monogamous (lying, deception,
etc.) are not integral to the phenomena.

An exhibitionist is someone who enjoys displaying him
or herself nude, in sexy dress, or engaging in sexual behavior in front
of others; a voyeur is someone who enjoys watching a sexual
display. Both exhibitionism and voyeurism may be consensual or nonconsensual.
The nonconsensual versions are illegal.

Someone can be turned on by dressing in specific garments (drag),
which include latex, PVC (polyvinyl chloride), leather, and corsets. For
some people, their outfit defines the fantasy that they are playing out.
For the TV or transvestite, thepony girl/boy(someone
who dresses up as a pony to pull a wagon or carry a rider), the furrysex
aficionado (someone who role-plays being an animal having sex), or the
infantilist
(someone who role-plays being an infant), dressing up may be integral to
the experience. For others it is a more comfortable way to present themselves
to the world; this is not drag, but implies a desired life
role. It is the difference between dressing to enhance sexual arousal and
how one wishes to be perceived.

Afetishis an erotic attraction to an inanimate
object, or to a particular aspect of a human partner; some sexologists
distinguish between a fetish(erotic attraction to an inanimate
object) and a partialism (an erotic attraction to a body
part). Common fetishes include shoes, cigars or cigarettes, and materials
such as rubber or leather. Common partialisms are feet, breasts,
buttocks, hair, and body fluids such as urine, blood or sweat. Fetishwear
are costumes designed to provoke a fetishistic response, such as corsets,
boots and leather motorcycle gear.

Many kinds of non-traditional erotic behaviors do not include conventional
genital sexuality. Do not assume that your patient's involvement in fetishism,
S/M, crossdressing or other erotic activities necessarily means that genital
stimulation occurs while involved in these activities.

Cross-dresser is a generic term for all those who dress
in the clothes of the opposite sex.
Gender-fuck describes
a person or activity that involves someone dressing with stereotypic aspects
of both men and women at the same time (e.g., having a full beard while
wearing a dress). A female impersonator or gender illusionist
dresses as a woman as part of a theatrical performance. A drag queen
is a gay man who dresses and acts in a stereotypically feminine style,
sometimes to an outrageous and humorous extreme. A drag king
is a lesbian who dresses and acts in a stereotypically masculine style.

People who dress in the clothes of the other sex come in a variety of
types: Transsexuals(TS) are people who feel that they are
members of the other sex trapped in the wrong body. They usually desire
hormonal treatment and gender reassignment surgery (also called sex reassignment
surgery). They are often divided into MTF (male to female)
or FTM (female to male) andpre-opand post-op
groupings as appropriate. Transsexuals who do not intend to have surgery
are called
non-op. Transgendered (TG) people
are those who choose not to think of themselves as one gender or the other;
they may appear androgynous, or may appear as one gender at some times
and another at others. Some TG people are TS's
who do not desire surgery. Dressing in the clothes of the opposite sex,
sexually arousestransvestites (TV). Most, but not
all, people in this category are genetic men (although this question is
debated). A chick with a dick is a TG genetic
male, usually with the implication that her penis works and she will use
it during sex; it can also mean a genetic woman with a strap-on.

Intersex or IS describes individuals with
one of several biologic (genetic, physiological or anatomical) conditions
that produces physical aspects of both men and women. IS
individuals may or may not consider gender an issue for them.

All these categories are extremely fluid, and people who considers
themselves transgendered may dress the same, present the same way, and
have the same medical issues as those who consider themselves to be cross-dressers
or a transsexuals.

Sex workers are those who earn money for providing sexual
or erotic services. People who provide conventional sexual services are
called prostitutes, hookers, hustlers, whores, streetwalkers orcallgirls. Professional dominants, pro-dommes
or
dominatrices provide S/M scenes in exchange for money; male
professional dominants, andpro-subsor professional
submissives, do exist but are rarer. Phone sex workers, strippers and
exotic dancers, and professional escorts are also
usually considered sex workers.

A sex worker may or may not provide conventional sexual activities
such as intercourse and oral sex, and may or may not use safer sex strategies.
Most sex workers are at some degree of physical risk (assault, robbery,
rape, homicide) and legal risk (arrest for prostitution and related crimes).